Caring for the Sick Person

While "taking care of the patient" in competence had been pushing "caring for" the patient to the periphery of medical concerns, "caring for" the patient received a major impetus at Harvard during the 1920s. This section will consider what altruistic terms and virtues "caring for" replaced, why they had lost their meaning, an account of the onset of the term caring for, and its meaning in healthcare prior to 1982.

The moral term caring for was turned to at a time when the altruistic virtues that had shaped the care of the sick for centuries had lost much of their luster, particularly terms like hospitality, philanthropy, charity, love, and sympathy.

For example, hospitality, which meant the friendly and cordial taking in of strangers or travelers, had enormous influence as an altruistic virtue for healthcare; it was a model in rabbinic Judaism, early Christianity, and Islam (Exod. 23:9). Christianity had transformed hospitality from a private into a public virtue of mercy and beneficence that was often directed to the sick stranger (Bonet-Maury). Hospitality prompted establishment of travelers' inns, which evolved into hospices where healthcare was sometimes provided, and eventually to hospitals, especially in the Byzantine East but also eventually in the Latin West (Miller). But by the 1920s, this religious term had lost its force; even Christians no longer spoke of hospitality as a major public virtue motivating healthcare.

Philanthropy had, for centuries, been a dominant altruistic motive for "caring for" the sick in most religious traditions, but it has virtually disappeared from the moral sphere of healthcare. The ideal of philanthropy (from the Greek philanthropos, meaning humane or benevolent) encouraged a love of humankind that expressed itself in concrete deeds of service to others. Philanthropy, associated with the Christian ideal of charity, made it possible for the sick person to assume a preferential position in society (Sigerist) and motivated the establishment of hospitals starting in the fourth century in the East, until modern times in the West. The ideal of philanthropy also appeared strongly in the first code of medical ethics, adopted by the American

Medical Association in 1847. But by the 1920s, professional philanthropy, from which modern professionals had derived much of their authority and prestige, had lost much of its respect, and the significance of the word philanthropy had been reduced to its meaning of private (and to some extent, public) support of the arts, education, and research (May,

Sympathy and compassion have exerted a strong public influence on caring for the sick in times past, in particular by motivating the sensitivities of individual medical practitioners. Codes and oaths have exhorted health practitioners throughout the ages to care for the sick out of motives of compassion and sympathy. John Gregory (1724—1773) spoke of the sensibility of heart that makes us feel for the sick and arouses in us the desire to relieve their distresses. Use of the word sympathy to motivate personalized medical care appeared commonly right up to the 1920s and beyond. But the word sympathy lost its effectiveness as it often came to be regarded as the condescending manifestation of pity; the word compassion was looked on with some disfavor as it came to suggest too much identification with the suffering person.

In addition, there is an overarching reason why the previous caring virtues were discounted, leaving room for the new, secular term of care. In criticizing ecclesiastical institutions in the eighteenth century, Enlightenment thinkers denounced charity for the sick and philanthropic hospitals because these activities were tainted by the essentially self-centered gifts and legacies of pious people who sought to atone for their sins by acts of charity in support of the hospitals. Eighteenth-century rationalists emphasized that the poorly organized philanthropic hospitals of Christian Europe did little to help the sick get well; and some Enlightenment thinkers blamed the very concept of Christian charity for these abuses. Furthermore, Christian charity was regarded as too closely linked to dead traditions and blind superstitions to have a close relationship with science (Locke). The attempt by some philosophers in the eighteenth, nineteenth, and twentieth centuries to base an altruistic care of the sick on a secular notion of sympathy was, in part, a result of these developments.

By the 1920s, the secular term care had begun to replace the earlier altruistic terminology. By this time, the history of the idea of care had progressed to the point that the term was coming to be known for its moral implications. In addition, care had special appeal as a virtue for healthcare because the same word had—for centuries and in a variety of languages— been the descriptive term for "taking care of" sick people. It should be no surprise, then, that for a number of decades prior to 1982—when the idea of care began capturing widespread contemporary attention—there appeared a small body of literature in the clinical ethics of physicians and nurses as well as in religious medical ethics that focused attention on the moral meaning and practice of care, as well as on an ethic of care.